Before the District Consumer Disputes Redressal Commission, Rohtak.
Complaint No. : 381.
Instituted on : 09.07.2021.
Decided on : 22.08.2022.
Neha Arora aged 37 years w/o Late Sh. Parvesh Arora R/o H.No.657/23, D.L.F.Colony, Rohtak.
.......................Complainant.
Vs.
ICICI Prudential Life Insurance Co. Ltd., through its Director/Manager/Associate Regional Manager, 1st Floor, Ashoka Plaza, Delhi Road, Rohtak.
2nd Address:
Unit No.1A & 2A Tipco Plaza, Rani Sati Marg, Malad(East) Mumbai-400097.
3rd address:
ICICI Pru Life Towers, 1089 Appasaheb Marathae Marg, Prabha Devi, Mumbai-400025.
..……….Opposite party.
COMPLAINT U/S 12 OF CONSUMER PROTECTION ACT,1986.
BEFORE: SH.NAGENDER SINGH KADIAN, PRESIDENT.
DR. TRIPTI PANNU, MEMBER.
DR. VIJENDER SINGH, MEMBER.
Present: Sh. Lalit Nayyar, Advocate for the complainant.
Sh. Rajesh Sharma, Advocate for the opposite party.
ORDER
NAGENDER SINGH KADIAN, PRESIDENT:
1. Brief facts of the case are that Sh. Parvesh Arora husband of complainant got insured his life from opposite party on 19.03.2019 under insurance plan-ICICI Pru iProtect Smart Policy No.34942262 for a sum assured of Rs.One Crore and accidental benefit of Rs.One lakh for premium/yearly installment of Rs.98773/- plus GST every year up to five years for a policy term 46 years and policy to be end on 19.03.2065 by paying first premium amount of Rs.116553/- dated 19.03.2019 vide receipt no.4964486. At the time of issuance of policy, Parvesh Arora was hale and hearty and was not suffering from any disease. Medical tests of the insured were got conducted by opposite party from their designated/empanelled doctors at the time of issuing the policy. Unfortunately insured suffered from Covid-19 and was admitted to PGIMS Rohtak for treatment but during the treatment his life could not be saved inspite of best possible treatment and he was expired on 15.09.2020 in PGIMS, Rohtak. After the death of insured, complainant being the nominee in the policy submitted claim with the opposite party demanding for payment of Rs.One Crore i.e. insured amount but despite her repeated requests, opposite party lingered on the matter and repudiated the death claim of insured on the ground that insured/deceased was suffering from type–II diabetes mellitus since 17 years and hypertension since 2 years and this medical history is prior to said insurance policy. But in fact insured was neither suffering from diabetes nor hypertension at the time of issuance of said insurance policy and had died due to Covid19. Further it is submitted that at the time of admission in PGIMS, Rohtak he was partly senseless when he came to know that he is a Covid positive and when the history was asked by the concerned doctor, the deceased could not reply properly. The opposite party has paid back only Rs.2,33,106/- by credit in bank account of complainant without the consent of complainant which reflects that the claim is genuine. The act of opposite party is illegal and amounts to deficiency in service. Hence this complaint and it is prayed that opposite party may kindly be directed to make the payment of balance insured amount i.e Rs.97,66,894/-, to pay Rs.1,50,000/- as compensation and to pay Rs.50,000/- as litigation expenses to the complainant.
2. After registration of complaint, notice was issued to the opposite party. Opposite party in its reply has submitted that the opposite party had received proposal form bearing number OS10836495 alongwith CDF duly filled and signed by the Life Assured for ICICI Pru IProtect Policy. Based on the information provided in the proposal form, the policy bearing number 34942262 was issued on 19th March 2019 to the Life Assured. It is further submitted that proposal form submitted by the Life Assured had the declaration and authorization, which was duly signed by Life Assured stating that in case of any misstatement or suppression of material information, the Company has the right to repudiate the claim under the Policy. It has been proved beyond doubt that the DLA was suffering various ailments at the time of taking the policy. It is important to mention that considering the age of the DLA the policy was issued under the Non-Medical Category. Even if the medicals were conducted the DLA was bound to disclose his medical status correctly. It is well settled principle of law that a “nominee” of insurance policy is not the beneficiary under a Life Insurance Policy. The complainant lodged death claim under the policy vide claim form dated October 06, 2020 informing the company that the Life Assured expired on September 15, 2020 from Covid 19. It was an early claim and after careful evaluation of the records obtained by the company, during the claim processing and investigation, it is noted that he was suffering from Diabetes Mellites type 2 since 17 years and on insulin injection & Hypertension since 2 years was under treatment for the same. This medical history was prior to the policy issuance. The death summary from PGIMS Rohtak was obtained during claim processing by the investigator, which clearly establishes the said fact that the Life Assured had given false replies to the question regarding health and lifestyle in the proposal form. Life insured had not disclosed the full, complete and correct facts regarding his health. The opposite party company had sent a letter to the complainant seeking medical documents of the DLA but the same have not been provided by her due to the reasons best known to her. Hence the subject claim of the complainant was repudiated by the company. The same was duly intimated to the complainant vide letter dated 09.04.2021 and the premium of Rs.233106/- under the policy was refunded to the claimant vide NEFT on 21.05.2021. All the other contents of the complaint were stated to be wrong and denied and opposite party prayed for dismissal of complaint with cost.
3. Ld. Counsel for the complainant in his evidence has tendered his affidavit Ex.CW1/A, documents Ex.C1 to Ex.C9 and closed his evidence on dated 29.10.2021. Ld. Counsel for opposite parties has tendered affidavit Ex.RW/A, documents Ex.R1 to Ex.R11 and closed his evidence on dated 27.01.2022. Ld. Counsel for opposite parties has also tendered Ex. R-12 in his additional evidence and the same was closed on 08.07.2022.
4. Written arguments filed by ld. counsel for the complainant. We have heard learned counsel for the parties and have gone through the written arguments as well as material aspects of the case very carefully.
5. In the present case the claim of the complainant has been repudiated by the opposite party on the ground that the life assured was suffering from Diabetes Mellites type 2 since 17 years and on insulin injection
& Hypertension since 2 years and was under treatment for the same before issuance of the policy. It is further contended that the death summary from PGIMS Rohtak was obtained during claim processing by the investigator, which clearly establishes the fact that the Life Assured had given false replies to the questions regarding health and lifestyle in the proposal form. It is further contended that the premium of Rs.233106/- under the policy was refunded to the claimant vide NEFT on 21.05.2021.
6. We have observed the documents placed on record by both the parties. As per the document Ex.R12 placed on record by the opposite party, which is summoned from PGIMS Rohtak, the life assured was admitted in PGIMS, Rohtak on 11.09.2020 and was discharged on 15.09.2020 for the diagnosis “HTN with T2 DM with COVID-19 and the cause of death is written as ‘COVID 19 pneumonia”. But the opposite party has not placed on record any document to prove the fact that life assured was taking treatment either from PGIMS Rohtak or from any other doctor regarding diabetes. It has not been established from the summoned record that the deceased took any treatment prior to this admission regarding the diabetes Mellitus from PGIMS, Rohtak. Moreover the deceased was admitted in PGIMS, Rohtak for a long time, the respondent has summoned the record of deceased from PGIMS we.f. 15.09.2020 to 01.10.2020, which is for the treatment of Covid-19 only. The record of PGIMS, Rohtak has not established that the treating doctor gave any treatment or medicines of diabetes to the deceased. No detail of prescribed medicines has been placed on record to prove the fact that after the admission in PGIMS, Rohtak, the deceased took any medicine for the treatment of diabetes. No blood or urine report or any authentic report has been placed on record to prove that at the time of admission or during the treatment, life assured was suffering from diabetes. Moreover diabetes is a lifestyle disease and not an infectious disease. We have also placed reliance upon the law cited by ld. counsel for the complainant of Hon’ble National Commission, New Delhi in 2009(3)CLT 583 titled as Life Insurance Corporation of India Vs. Kulwant Kumari , which is fully applicable on the facts and circumstances of the case. In view of the aforesaid law and facts and circumstances of the case it is observed that the claim of the complainant has been wrongly repudiated by the opposite party and there is deficiency in service on the part of opposite party. As such opposite party is liable to pay the claim amount to the complainant as per policy. As per policy Ex.C7, the death claim under the policy is Rs.1,00,00,000/- and opposite party has already paid the amount of Rs.233106/- which is not denied by the complainant. As such opposite party is liable to pay the remaining amount of Rs.9766894/- to the L.Rs. of deceased. As per Claim Investigation Report Ex.R5, the L.Rs of the deceased as mentioned at page No.2 of the report are: 1. Satya( Mother), 2. Neha wife, 3. Ruchika Daughter and 4.Vivan (Son).
7. In view of the fact and circumstances of the case we hereby allow the compliant and direct the opposite party to pay the amount of Rs.9766894/- (Rupees ninety seven lacs sixty six thousand eight hundred and ninety four only) alongwith interest @ 9% p.a. from the date of order i.e. 22.08.2022 till its realization and shall also pay a sum of Rs.10000/-(Rupees ten thousand only) as compensation on account of deficiency in service and Rs.5000/-(Rupees five thousand only) as litigation expenses to the L.Rs of the deceased Parvesh i.e. 20% of the awarded amount shall be paid to the mother of deceased i.e. Satya, 40% to the wife of deceased i.e. Neha, 20% to the daughter of deceased i.e. Ruchika and remaining 20% to the son of deceased i.e.. Vivan within one month from the date of decision. It is made clear that the share of minor children i.e. Ruchika and Vivan shall be deposited in any nationalized bank in the shape of FDR and shall be disbursed to them on attaining the age of majority.
8. Copy of this order be supplied to both the parties free of costs. File be consigned to the record room after due compliance.
Announced in open court:
22.08.2022. ................................................
Nagender Singh Kadian, President
………………………………..
Tripti Pannu, Member.
………………………………..
Vijender Singh, Member.
